AMA Clinical Examples in Radiology - 2015 Issue 1 (Winter)
Radiology Test Case: Left Breast and Axillary Ultrasound
Radiology Test Case: Radiology Test Case The radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Consider your answers as to how the procedure is reported in 2015. Once you are confident with your answer, turn to page 10 for the correct answer and discussion. Left Breast and Axillary Ultrasound CLINICAL HISTORY 33-year-old female with left breast swelling. No known family history of breast cancer. PHYSICAL EXAMINATION Negative left breast and left axilla. Left breast larger. There is no edema. TECHNIQUE Ultrasound evaluation of the left...
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Article Overview
This article presents a radiology test case intended for coding professionals who want to review a breast and axillary ultrasound encounter in a test-and-discussion format. It covers the clinical presentation, imaging approach, documented findings, and the follow-up assessment and recommendation context, making it useful for coders working with breast imaging, ultrasound documentation, and radiology reporting in a 2015 coding environment.
Why This Topic Matters
Breast and axillary ultrasound reports often require careful interpretation of the documented exam scope and report structure. This case helps readers evaluate whether a study is fully described and how the report is organized before comparing their interpretation with the provided discussion.
Article Sections
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Left Breast and Axillary Ultrasound
Introduces the clinical scenario and the imaging study being reviewed. Provides the patient context and the general reason the exam was performed.
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Clinical History
Summarizes the patient background and presenting concern relevant to the imaging evaluation.
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Physical Examination
Notes the relevant exam observations documented before imaging interpretation.
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Technique
Describes the ultrasound regions evaluated and the documentation approach used during the study.
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Findings
Presents the imaging observations from the evaluated breast and axillary areas.
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Assessment
Summarizes the imaging assessment category assigned in the report.
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Recommendation
States the follow-up and clinical correlation recommendation included with the study.
What You Will Learn
- How a breast and axillary ultrasound case is structured in a radiology report
- Which parts of the report support coding review and exam interpretation
- How follow-up assessment and recommendation language are presented in a test case format
- What information a coder should look for when reviewing imaging scope and documentation
Who Should Read This
- Medical coders
- Radiology coders
- Coding auditors
- Radiology documentation specialists
- Health information professionals
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